News | Jan. 1, 2016

Separate and Equal: Building Better Relationships with the International Humanitarian Community

By Paul A. Gaist and Ramey L. Wilson Joint Force Quarterly 80

Paul A. Gaist, Ph.D., MPH, is an Adjunct Professor at the Johns Hopkins Bloomberg School of Public Health and a Health Scientist Administrator at the National Institutes of Health. Lieutenant Colonel Ramey L. Wilson, USA, MD, MPH, is a General Internal Medicine Fellow at the Walter Reed National Military Medical Center and an Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences.

You can’t surge trust.

—General James Amos,
Commandant of the U.S. Marine Corps1

In today’s complex global landscape, understanding and taking the opportunities to build peace to prevent war are increasingly paramount if a stable and sustainable world is to be realized. As such, we need to sharpen the focus of the roles the military and the humanitarian assistance community have in this important call to action and, at the least, determine what each side needs to know about the other. This is especially true if we are to find those intersections and circumstances where the military and the humanitarian assistance community are able to work together and to recognize those where they cannot. Toward this goal, this article reviews the identity, principles, and culture of the humanitarian community, what it expects from military forces, and what it wants the military to consider when it is planning health engagement. Additionally, approaches and methods for constructive interaction between the military and community forces are proposed.

U.S. Air Force Combat Controller from 23rd Special Tactics Squadron, Air Force Special Operations Command, Hurlburt Field, Florida, watches pallets after airdrop of humanitarian aid for distribution in Port-au-Prince, Haiti, following magnitude 7 earthquake, January 18, 2010 (U.S. Air Force/James L. Harper, Jr.)

U.S. Air Force Combat Controller from 23rd Special Tactics Squadron, Air Force Special Operations Command, Hurlburt Field, Florida, watches pallets after airdrop of humanitarian aid for distribution in Port-au-Prince, Haiti, following magnitude 7 earthquake, January 18, 2010 (U.S. Air Force/James L. Harper, Jr.)

To begin, the military should refrain from referring to the international humanitarian community as partners. The use of this word in general denotes both an identity and a relationship between two or more entities that are sharing in potential risks and gains. In this sense, it is assumed and accepted that in a partnership, the affiliations, obligations, and consequences of one partner’s behavior extend to the other (such as with co-owners of a business). In the contentious, unsafe, and challenging environments in which both the military and civil society organizations work as a matter of course, the words we use can have enhanced meaning and consequences. In this regard, it is important that the civil society sector not be defined by an actual or perceived association with the military. Thus, the military should find a word other than partner to describe the relationships it has with the civil society sector without suggesting commingled identities; co-equals, co-actors, or colleagues would be more acceptable. Referring to those in the international humanitarian community as partners is an association that can put them in harm’s way, and this is a main reason for not using this term. Another reason is the way in which the military now uses the word to define its relationship to the humanitarian community. With the word partner saturating the 2012 strategic guidance in Sustaining U.S. Global Leadership: Priorities for 21st Century Defense and the recently revised National Security Strategy, its meaning has subtly shifted in the military’s parlance. Its use by the U.S. Government (and, by definition, the Department of Defense) no longer suggests an independent organization that works as a co-equal, but now implies a relationship to use and leverage a subordinate organization to serve U.S. interests. Just as then–Secretary of State Colin Powell infamously revealed the U.S. Government’s perspective regarding nongovernmental organizations (NGOs) by declaring them “force-multipliers” and “an important part of our combat team” in 2001, the word partner means something different to the military than it does to the international humanitarian community.2 Speaking from that community’s perspective, the words and terms we use can directly impact the ability to find avenues and opportunities where coordination, cooperation, and possibly collaboration can exist. So let us start by using a different term to indicate working arrangements and/or agreements that may be formed and realized. To convey this and other key points with direct clarity, this article speaks from the perspective and with the voice of the civil society sector that is based on the authors’ experience working in and with the international humanitarian community. As such, and as in the field, the authors span the military, health, and humanitarian professions to provide insight about these key cultures and speak to the essentials required for them to work effectively and productively together.

Working Together: The Civil Society Perspective

While we, the civil society sector, may not agree with the military’s use of the word partner, we can seek ways to work in partnership, in the form of conditional working relationships, as a means to cooperate on mutual goals and aims to relieve suffering and prevent unnecessary death. The key is that those efforts are and will be highly contextual based upon the time, place, circumstances, culture, mandates, and objectives of each actor and situation. The recent partnership of U.S. military and humanitarian medical forces in response to the Ebola crisis in Liberia highlights the fluid relationships that will shift based upon each specific context, especially the level of violence. During disaster responses or epidemic outbreaks, there is no doubt that military forces possess unique skills and equipment that can assist with the response. In areas of conflict or violence, however, the distance between the military forces and the humanitarian community must increase to protect the humanitarian space, especially when military or political objectives extend beyond relieving suffering or building capacity.

U.S. Soldiers assigned to Company C, 1st Battalion, 17th Regiment, unload humanitarian aid for distribution to town of Rajan Kala, Afghanistan, December 5, 2009 (U.S. Air Force/Francisco V. Govea II)

U.S. Soldiers assigned to Company C, 1st Battalion, 17th Regiment, unload humanitarian aid for distribution to town of Rajan Kala, Afghanistan, December 5, 2009 (U.S. Air Force/Francisco V. Govea II)

The reality is that military forces will most likely be collocated with the humanitarian community for the foreseeable future, even in areas of violence or insecurity where the humanitarian community desires a distinct separation from belligerent forces for their own protection. In 1991, after the highly effective response in Iraq by the humanitarian community and coalition military forces during Operation Provide Comfort, we hoped that our partnership would signal a new model for civil-military interaction. Subsequent complex emergencies in Europe and Africa and the wars in Iraq and Afghanistan, however, demonstrated that continued efforts to improve the coexistence of humanitarian organizations and military forces operating in conflict areas were needed. With the recent international response to the Ebola crisis and the new U.S. Government strategy of proactive engagement, especially in the domain of health, it seems fitting to revisit and review the principles and culture of the humanitarian community. Maybe the Ebola response in Liberia can be a tipping point for improved collaboration and partnership as we move forward, further building on the successes achieved while responding to recent natural disasters.

Who We Are

The international humanitarian community comprises the various organizations and institutions that seek to relieve the unnecessary death and suffering that comes from various sources, such as poverty, conflict, and injustice. Seen broadly, the community includes financial donors, international governmental organizations (IGOs), and NGOs, each of which serves a different function. Overall, these groups are often referred to under the umbrella term civil society organizations (CSOs) and/or the civil society sector. Financial donors provide the funding for humanitarian work and include state entities, intergovernmental bodies (which receive their funding from the states that participate in the institution), and private donors/foundations. Intergovernmental bodies, which serve as both funding conduits and coordinating agencies of policy and implementation, include the various institutions of the United Nations (UN) and other multistate organizations. Nongovernmental organizations vary considerably and characterize themselves by function—advocacy based or operational—and their scope of effort—community based, national, transnational, or international. While advocacy based NGOs work to illuminate problems and promote change at the policy level, operational NGOs work to provide direct support to those in need, usually at the local level, and are more numerous. In general, NGOs serve four basic areas of need: humanitarian assistance, human rights, civil society/democracy-building, and conflict resolution.3 Health and public health objectives relate to all these areas and are often priority goals within them.

What We Believe

We appreciate that the military has its own culture, objectives, and ways of operating, which we need to better understand. In turn, it is key that the military understand our beliefs, culture, and operations.

While each NGO and humanitarian IGO has a different mandate, objective, culture, and willingness to engage with military forces, the majority define themselves as humanitarian by identifying with the core principles of humanitarian action, first proposed by the International Committee of the Red Cross (ICRC) and Red Crescent Movement: humanity, impartiality, neutrality, and independence.

Humanity. The principle of humanity states that all human suffering is anathema and must be recognized and addressed wherever it is found. It focuses all activities on preserving and protecting the life and health of those in need and respecting others as fellow human beings. While military forces may be able to readily follow the spirit of this principle during a disaster response, they directly violate this principle in the conduct of military operations designed to destroy or kill enemy combatants or when noncombatants are placed at risk during military operations.

Impartiality. The principle of impartiality articulates that all assistance and care must be distributed solely based on need, with priority given to those who need it most. There can be no distinction on the delivery of assistance based upon age, nationality, race, gender, religious belief, class, language, disability, health status, sexual orientation, political opinion, or social origin. While military forces can act with impartiality during disaster responses and humanitarian crises, this is impossible when they are acting as a belligerent or in support of another political entity. As such, the current strategy of the military to use health and medicine as a soft power to “win hearts and minds” is a direct affront to humanitarian principles. Military health engagements do not always target those with the greatest need, but are often provided in an effort to strengthen or change a particular group’s political perspective and/or as part of a strategy to achieve non–health-related military objectives.

Neutrality. Often the only way CSOs are able to do their work is if they are seen as being neutral—not taking sides one way or another. It is not that we are blind to the injustice we may know and witness; in fact, that injustice is often what fuels our commitment and our often extraordinary efforts. To gain and maintain access in conflict zones to carry out our work, it is critical that we not be viewed as standing for and/or promoting one side or another. Specifically, the principle of neutrality declares that humanitarian organizations must not take sides in any hostilities or engage in controversies of a political, racial, religious, or ideological nature. As military forces serve as tools to political entities, they are, by definition, never neutral, even if operating under conditions where they seek to be neutral, such as part of a peacekeeping force.

U.S. Marine assigned to Special-Purpose Marine Air-Ground Task Force Crisis Response–Africa prepares to land at U.S. Embassy in Monrovia to support
Operation United Assistance in Liberia, October 13, 2014 (U.S. Marine Corps/Andre Dakis)

U.S. Marine assigned to Special-Purpose Marine Air-Ground Task Force Crisis Response–Africa prepares to land at U.S. Embassy in Monrovia to support Operation United Assistance in Liberia, October 13, 2014 (U.S. Marine Corps/Andre Dakis)

Independence. The principle of independence proclaims that humanitarian efforts must remain autonomous from other objectives, such as political, economic, military, or other motives, which may attempt to influence the location or operations of humanitarian action. As declared by Médecins Sans Frontières (Doctors Without Borders), “[we] strive to ensure that we have the power to freely evaluate medical needs, to access populations without restriction and to directly control the aid we provide.”4

Further summarized in the Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief, the principles seek to protect humanitarian actors from engaging in efforts that might fall outside humanitarian themes. Of special note to those in the military, Principle 4 of the Code of Conduct specifically warns us against working too closely with military forces for fear of losing our independence or being used—either knowingly or unknowingly—as a source of intelligence. As of April 10, 2015, there were 560 different NGOs that had formally endorsed the ICRC Code of Conduct and many others who embrace and operationalize its principles.

With these core principles underlying all humanitarian action, it is clear that our partnerships with the military will vary significantly based on the situation and context. The very principle of independence allows each NGO to establish its policies of collaboration and partnership with military forces, but the military should anticipate that its working relationships with us will change as operational contexts vary. In general, one of the following levels of engagement with most NGOs or IGOs should be expected:

Principled Non-Engagement. NGOs or IGOs will avoid almost all collaboration and partnership to avoid any actual or perceived loss of their independence. Institutions such as the ICRC and Médecins Sans Frontières usually hold this perspective.

“Arm’s-Length” Interaction. NGOs are willing to interact only indirectly through an international or regional intermediary, such as the UN Assistance Mission in Afghanistan, or through nonmilitary state institutions, such as the U.S. Agency for International Development’s Office of Foreign Disaster Assistance. This interaction emphasizes our perceived distance from military forces and our principle only to engage with military forces as a last resort.

Proactive, Pragmatic, Principled Engagement. NGOs will consider working in concert with military forces as long as humanitarian principles are protected and the mission is conducted under the auspices of a larger humanitarian effort, such as part of the UN Cluster System, to respond to a humanitarian emergency. While similar to the previous level of interaction, the perceived distance from military forces is decreased. Additionally, we may be willing to develop relationships with militaries through conferences or international bodies to proactively discuss and consider interaction when military units engage in relief activities.

Active, Direct Engagement and Cooperation. This level of interaction may only be possible during a disaster response or when military missions, such as those conducted by military hospital ships, closely follow humanitarian principles.5

Our Culture

Military forces should consider interacting with us as a cross-cultural experience, an opportunity to see the same problems or challenges through a different lens. To improve the chances of beneficial interaction, it is essential that the military have a basic grasp of our culture and history. Before we talk specifically about our culture, we want to emphasize that we take the previously discussed principles of humanitarian action seriously. They are what define our efforts and unify the humanitarian community. Military forces may be tempted to dismiss those principles as idealistic or negotiable, but we would encourage them to resist that temptation. Those humanitarian principles are our core values. Failing to understand them and their implications could lead to actions that would poison any interaction we might have in the future.

Worker decontaminates caregiver leaving patient area of active Ebola treatment center built as part of Operation United Assistance in Suakoko, Liberia, November 22, 2014 (U.S. Army/Brien Vorhees)

Worker decontaminates caregiver leaving patient area of active Ebola treatment center built as part of Operation United Assistance in Suakoko, Liberia, November 22, 2014 (U.S. Army/Brien Vorhees)

Although the humanitarian community agrees on the humanitarian principles, we do not all agree on how those principles should be implemented. We are a family, and like most families, we often disagree on the details. This independence springs from our heritage, a culture of independent action and autonomy, and our decisionmaking processes; we are not a hierarchical community that operates in a way the military is familiar with. We often operate by consensus and seek out collaboration, usually understanding that none of us can tackle any of the major problems by ourselves. Evolving over time, these collaborations have led to common standards for humanitarian assistance that support the principles of humanitarian action.

The humanitarian community looks to the establishment of the ICRC in 1859 in response to the lack of concern and medical care for the wounded left to die after a battle near Solferino, Italy, as the formal beginnings of humanitarian action. In 1863, the ICRC conducted the first of many Geneva Conventions that established the humanitarian principles and neutrality of medical forces, demanded care for all wounded, and codified the protections for civilians on the battlefield, thereby recognizing that non-belligerents, which include wounded enemies, have rights and need protection from abuse. With the end of the Cold War and the subsequent complex emergencies of the 1990s, we experienced an exponential growth in the number of humanitarian organizations that wanted to provide disaster relief, respond to a broad range of humanitarian crises, and build civil society globally. As occurs with any rapid growth, the quality of the assistance provided by these new NGOs varied considerably, ultimately leading to the professionalization of humanitarian workers, the establishment of response standards, and improved outcomes.

The humanitarian response standards, initially codified as the Sphere Project, initiated a process that sought to identify and teach the minimum standards that we needed to operate safely and effectively.6 It also defined specific measures and indicators in a number of areas: water supply, sanitation, hygiene promotion, food security, nutrition and food aid, shelter, settlements, non-food items, and health services. By establishing a set of common standards, we significantly improved collaboration, and the standards of the Sphere Project stimulated the development of other standards, such as the Code of Good Practice in human resource management and the Human Accountability Partnership Standard for accountability and quality management. All of these standards are now being combined into Core Humanitarian Standards, which will assist in coordinating efforts across the humanitarian space.7

As a result of the demands of various disasters ranging from earthquakes to tsunamis and fragile states to war, the humanitarian community has developed into a cadre of professionals operating as a learning organization and a network of networks that is capable, competent, and adaptable. We are adept at working with many groups, and the military is only one of many actors that seek to have working relationships with us. Our respective cultures will likely clash and create the potential for false expectations and misunderstanding, but we should be able to work through those issues if the need is great enough. While the humanitarian community is a heterogeneous group of organizations having different styles and mandates, our focus never waivers on the goals, principles, and practices that drive our humanitarian action. As we move forward, we encourage the military to consider us co-equals and to look for opportunities both to learn from us as well as to teach us about military cultures.

What We Want from the Military

How can we work together in a way that benefits both of our objectives and mandates? To begin, we need opportunities in safe and neutral spaces/communication channels to learn about each other in a forthright and constructive manner. Collectively, we should also design and conduct value-added needs assessments and establish expectations concerning working separately or together in the same disaster areas and conflict zones. To accomplish even these small steps, we need the military to understand us as embodied through humanitarian principles and to deal with us with honesty and transparency.

The humanitarian principles, as previously mentioned, provide the lens through which we view and calibrate all of our actions and those of others operating in the name of humanitarian action. They establish our boundaries (which the military calls “left and right limits”) and define our purpose of action. That said, we as a community are also quite pragmatic and understand that the military is not the “enemy.” Often, we want the same thing. Sometimes, however, military and police forces are part of the problem that is creating and sustaining humanitarian crises. When the military partners with forces or countries that are violating human rights, it should expect us to be less willing to work with it or else be perceived as a collaborator. Even international military forces operating under a UN banner have been known to perpetrate humanitarian crimes on those they were sent to protect.8 We see these actions, when they occur, as an assault on core humanitarian values and “grim reminders that working with military forces may have unforeseen, unintended consequences.”9

When we choose to distance ourselves from the military, we are not signaling that we consider it our enemy any more than it should view us that way. Our principles often call us to work in those gray areas among belligerents to provide care to those who are caught in the middle. We reject a polarized perception that states, “you’re either with us or against us” as too simplistic a way to view a complicated world. We can work through that complexity to find areas of cooperation—even collaboration—if the military understands our principles and works with us with transparency and veracity. Transparency does not mean that military secrets have to be divulged or that Servicemembers have to be put at risk, but it does require honesty regarding the motives of military actions and proposed health engagements. We would much rather clearly know the military’s desired objectives and limitations in health and medical engagement and engage in open discussion on how we might work together. Hidden agendas or objectives, especially if contrary to our humanitarian principles, undermine any trust we can build and are a major barrier to having any type of prolonged engagement with the military. Simply put, that approach is a non-starter and, if discovered once we are working together, a deal breaker.

In addition, it would be productive and helpful if the military would focus on its areas of expertise and let us focus on our areas of competency. We see only problems when the military attempts to become a quasi-developmental organization, often putting individuals in charge who have little or no experience or training in humanitarian action and who fail to fully understand the complexities of aid delivery and development.10 As one example of this, the lack of systematic follow-up and evaluations after most health engagements leaves the military uninformed and blind to the actual impact, positive or negative, of its engagements. In fact, we struggle at effective evaluation and follow-up as well. Maybe this could be an area of improvement that we pursue together.

What We Want the Military to Consider When Conducting Health Engagements

We are a pragmatic group and can see that U.S. military forces probably are going to be used to a greater extent in the development and health domains in support of the current National Defense Strategy. While we may not internally agree on the implications of these new medical diplomacy operations, there is no doubt that the military has robust capabilities to operate in austere, uncertain environments. These capabilities, however, were designed primarily for warfighting and may be inappropriate for health development and disaster assistance, especially if applied without an understanding of the local health context. Given the military engagement strategy in global health, the new Global Health Security Agenda, and the recent increases in the number and severity of natural disasters and potential civil unrest predicted with continued global climate change and other global pressures, we anticipate increased use of military forces in health and disaster engagements. We therefore entreat the military to consider, prima facie, the following question when conceptualizing and planning health engagements and responses: “Is this engagement doing more harm than good?”

The beneficence of a humanitarian or health engagement may seem, at first consideration, self-evident and obviously in the affirmative, but we encourage you to think more deeply about this question. You can even talk with us about this. Almost always, if not always, we would tell you that you should start by identifying the various stakeholders, the potential positive and negative impacts of the engagement, and how those impacts are prioritized. You need to ask yourself whether you are willing to undermine the effective delivery of humanitarian assistance or health development to achieve your strategic objectives. Furthermore, is it possible to conduct your health engagement in a manner where all stakeholders, especially those with a minimal voice, benefit from the engagement? How are you protecting those who are most likely to be harmed by your operations? Does your action increase or decrease the “humanitarian space” in which we operate? What are the economic impacts to the local health system and humanitarian community? Are you undermining the confidence and long-term viability of the local health system? Are you supporting the delivery of care that meets the standards of the local health system? What type of follow-up or longitudinal care are you providing?

Another complementary approach would be to plan and analyze the near-, mid-, and long-term impacts of your engagement with steps to measure the impact so that you can learn from your experiences. It is quite clear that the impacts of the alleged Central Intelligence Agency’s (CIA) sham vaccination program as a cover to find Osama bin Laden continues to have a significant negative impact on international health and development. As the CIA is involved with security, as you are, we associate you with those at the CIA and suspect that they are embedded in your ranks. Humanitarian workers and others have subsequently been killed because of the “maligned” vaccination program and you have set back progress (which requires community trust and acceptance of us and our work) for years, if not permanently, in the international efforts to eradicate polio and other significant health threats. In many parts of the world where we are most needed, vaccination programs were already culturally or otherwise viewed with suspicion and met with resistance. Now there are evidential counter-arguments defensively presented from the people and their communities when we try to explain and overcome such mistrust and reluctance. Going forward, do not be surprised if any efforts you make to support or develop vaccine programs, or any other health engagement for that matter, are viewed suspiciously as covert attempts to accomplish a military or security mission.

Our third suggested approach when considering a global health engagement or health intervention is for you to analyze your proposed operation through the lens of public health ethics.11 The 12 principles espoused in public health’s code of ethics should challenge all who engage in humanitarian action so that those who are most vulnerable to exploitation are protected, local health systems are strengthened, the engagements improve a current gap or deficiency in their health system, and the engagement is conducted with minimal negative impact and a greater likelihood of sustainability and success. These ethics call for engagement with indigenous populations, communities, and humanitarian organizations in order to include effective outreach as an integral aspect of all phases of the engagement, including follow-up. To date, we are unaware of any formal military medical ethic that is being used to systematically evaluate and balance the potential positive and negative impacts of military health engagements.

Sailors provide humanitarian assistance in support of Operation Tomodachi (U.S. Navy/Patricia R. Totemeier)

Sailors provide humanitarian assistance in support of Operation Tomodachi (U.S. Navy/Patricia R. Totemeier)

The Way Ahead

Of course, we in the humanitarian community have room for improvement as well. Good intentions are not enough, neither for you nor us. Continued work must be done to improve the planning, delivery, and measurement of aid and humanitarian action, and this is something that we can work on together. We must continue to find those areas of mutual interest and effort so that we can use them to develop a greater level of trust and cultural understanding. For example, developing better assessment and communication tools to make timely and useful distinctions about our objectives will help determine our working relationships. This in turn will allow us to collectively improve our ability to identify, map, and plan contingencies and improve our effectiveness in disaster areas and conflict zones. As part of this, maybe your concept of interoperability is an approach that we could use to guide our future work together. In this context, we understand interoperability to be the ability for our organizations to work together, from planning to the delivery of aid, in a way that minimizes the differences in equipment or processes that lead to the unnecessary loss of life or property and increases efficiencies in the overall use of available funds and other resources. The use of the UN Cluster System, for example, is an organizational process that facilitates early response and information dissemination. The Sphere Project guidelines provide another tool that establishes both a framework and a standard for collective response that approaches an evidence-based method. What about exploring and developing the concept of interoperability in the areas of medical equipment and supplies, evacuation processes, and responses? This would allow military forces and the humanitarian community to provide coordinated responses, cross-level supplies, and minimize the transition of care when military forces depart. Can this same principle of interoperability be applied to non-disaster engagements so that we are not working in cross-purpose with each other? To this end, we need health development and engagement professionals in the military and Federal service who can bridge the divide among our organizations at all levels of engagement and who are representative of all services, from strategic to the tactical, who have cultural and language skills to appropriately assess, understand, and partner in the health domain. Similarly, you need to further explore creating opportunities for our representatives to work in concert with your planners and implementers. There has been significant work and partnership in these areas over the past several years, but more effort and focus are needed.


The humanitarian community has a long history of advocating for and assisting those in need throughout the world. And as recent Kaiser Family Foundation reports in 2014 and 2015 re-emphasized, NGOs (both U.S. and foreign) play an important role in and are key implementers of global health efforts.12 As you expand into the health domain of development, we want you to know that we do this work professionally; we know what we are doing. The lessons we have learned have led to the professionalization of humanitarian action according to the humanitarian principles that emphasize the concepts of humanity, impartiality, neutrality, and independence. Our cultures are different and if we are to co-exist and work toward common goals to meet the needs of others and strengthen the resiliency of their health systems, you must understand the nature and importance of these humanitarian principles. From us, you can be confident that we are willing to do the hard work to better understand your cultures and modes of operation that will allow us to better establish either working relationships or our distance, depending on what is assessed to be the most appropriate in a given context or situation. We hope that you have the same resolve. From you, we require honesty, transparency, and a respect for our principles and our core values. We are hopeful that this work will continue so that those in need can flourish in accordance with the respect and rights due to every person.

As just one example, there may need to be a rebalancing between operational security considerations and information-sharing in the health domain. For now, we must find mutually acceptable ways to establish productive working relationships or, at the very least, to co-exist in ways that do not increase the risks to our workers and/or our humanitarian objectives. It is only by choosing to understand the humanitarian principles, better relate to our culture, and meet us as co-equals that we will be able to forge mutually acceptable areas of communication, coordination, and collaboration. These key imperatives—ground rules, if you will—will allow us to work together in honest and productive ways as we confront and address the many challenges ahead. With formal dialogue, preplanning, understanding, and agreements, together we can find improved and constructive ways to do this. There are significant opportunities for us to make progress toward our mutual goals, to efficiently improve medical and public health assistance and systems in both the short and long term, and to do this in more effective, cost-effective, and sustainable ways. We look forward to working with the military toward these goals, where we can, to create a safer, healthier, and more just world. JFQ


1 John Grady, “USMC Commandant: ‘You Can’t Surge Trust,’” United States Naval Institute News, April 10, 2013, available at <>.

2 In I.T. Katz and A.A. Wright, “Collateral Damage—Médecins Sans Frontières Leaves Afghanistan and Iraq,” New England Journal of Medicine 351, no. 25 (December 2004), 2571–2573. The actual transcript for the quotation by Secretary Colin Powell on the U.S. State Department Web site has been removed.

3 Robert M. Perito, Guide for Participants in Peace, Stability, and Relief Operations (Washington, DC: U.S. Institute of Peace Press, 2007).

4 Médecins Sans Frontières, charter and principles, available at <>.

5 Gerard McHugh and Lola Gostelow, Provincial Reconstruction Teams and Humanitarian-Military Relations in Afghanistan (London: Save the Children, 2004), available at <>.

6 Sphere Project Web site, available at <>.

7 Core Humanitarian Standards, available at <>.

8 Jospeh Loconte, “The U.N. Sex Scandal,” Weekly Standard, January 3–10, 2005, available at <>; “Kosovo UN troops ‘fuel sex trade,’” BBC News, available at <>; Emily Wax, “Congo’s Desperate ‘One-Dollar U.N. Girls’: Shunned Teens, Many Raped by Militiamen, Sell Sex to Peacekeepers,” Washington Post, March 21, 2005, A1, available at <>.

9 Ramey L. Wilson, “Disasters and Conflict Zones Around the World: The Roles and Relationships of Military and Nongovernmental Organizations,” in Igniting the Power of Community: The Role of CBOs and NGOs in Global Public Health, ed. Paul A. Gaist (New York: Springer-Verlag, 2010), 125.

10 Special Inspector General for Iraq Reconstruction (SIGIR), Learning from Iraq: A Final Report from the Special Inspector General for Iraq Reconstruction (Washington, DC: SIGIR, March 2013), available at <>.

11 James C. Thomas et al., “A Code of Ethics for Public Health,” American Journal of Public Health 92, no. 7 (July 2002), 1057–1059.

12 NGO Engagement in U.S. Global Health Efforts: U.S.-Based NGOs Receiving USG Support through USAID (Menlo Park: CA: Kaiser Family Foundation, December 2014), available at <>; Foreign NGO Engagement in U.S. Global Health Efforts: Foreign NGOs Receiving USG Support through USAID (Menlo Park, CA: Kaiser Family Foundation, May 2015), available at <>.